Crash Cart Medication

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Crash Cart Medication
Case scenario
Dr. Sabah Awad
Senior Specialist EM
Al-Nahdah Hospital
2017

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Objectives….
To train the health care provider on crash cart medications and
their practice in common emergencies ( case oriented ).
Mechanism of action
Main indications
Main contraindications
Dosages
Major side effect and precautions

3. The Crash Cart
It is a multi drawer wheeled cabinet with the essential medication and
tools that required in emergency situations.
Other names:
Emergency cart/Emergency response cart/Code
cart/Emergency trolley
PURPOSES:
•To provide immediate access to supplies and medications.
•To facilitate coordination of emergency equipment.
•To ensure a properly stocked crash carts will be readily available.
•To ensures a properly functioning defibrillator will be readily
available.
•To save the valuable time at the time of emergency .
3
.

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 Compromised Airway
Respiratory Distress /Respiratory Arrest
Cardiac Arrest /Abnormal cardiac rhythm
Drug Overdose
Hypoglycemia
Anaphylactic Reaction

5. A/ Top of emergency trolley (External
Contents)
•Oxygen supply
•Defibrillator with Monitor
• Portable suction apparatus
•Sphygmomanometer
•Stethoscope
•Emergency Crash Cart Check Sheet
•Check List of cart contents.
•Emergency drug information sheet
5

6. 6
Contents of the trolley…
B/Drawer contents (internal contents):
Drawer 1- Medications
Drawer 2- Breathing and Airway
Drawer 3- Circulation: IV supplies
Drawer 4- Circulation: I.V. solutions and tubing
Drawer 5- Cardiac, Chest Procedures
Drawer 6- Special Procedure Trays

7. Contents of the trolley….
Drawer contents:
Drawer 1- Medications
7

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•Adenosine
•Aspirin
•Atropine Sulfate
•Amiodarone
•Calcium gluconate
•Diphenhydramine
•Diltiazem
•Dextrose 50% ,25%
•Epinephrine 1:10,000
•Epinephrine 1:1000
•Magnesium sulphate
•Methylprednisolone
•Metoprolol
•Naloxone
•Lidocaine
•Procainamide
•Sodium bicarbonate
Analgesics
-Fentanyl
-Morphine
Sedatives/Induction agents
-Diazepam or midazolam
-Propofol or Thiopentone
-Ketamine
Muscle relaxants
-Non depolarising muscle
relaxants – atracurium,
rocuronium, vecuronium
-Suxamethonium

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Case scenario

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Case No. 1
33 year old women presented to local health center with
history of palpitation , dizziness , She denies any history
of chest pain or SOB.
Vital sign BP 135/75 , HR 160 /m, RR 16/m

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ADENOSINE CLASS Endogenous nucleoside, antidysrhythmic
•Decreasing electrical conduction through the AV node without causing negative
inotropic effects.
•Decrease chronotropic activity by direct effect on sinus pacemaker cells and
vagal nerve terminals .
ONSET AND DURATION Onset: Immediate Duration: 10 sec. *
INDICATIONS : First drug for most forms of narrow-complex paroxysmal SVT
and Wolff-Parkinson-White (WPW) syndrome in adults and pediatric patients.
*In undifferentiated regular stable wide-complex tachycardia, IV adenosine may
be considered relatively safe.
CONTRAINDICATIONS :
•Second- or third-degree atrioventricular block
•Hypersensitivity to adenosine.
ADVERSE REACTIONS * Facial flushing ,Light-headedness , Paresthesias
Headache, Diaphoresis,, Chest pain, Hypotension ,Transient periods of sinus
bradycardia, sinus pause, or bradyasystole *

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DRUG INTERACTIONS
•Methylxanthines (e.g., caffeine and theophylline) antagonize the action of
adenosine .
•Dipyridamole , carbamazepine potentiates the effect of adenosine; reduction
of adenosine dose may be required.
DOSAGE AND ADMINISTRATION *
•Adult:
Initial dose: 6 mg rapid IV bolus over 1-3 sec, followed by a 20-mL saline bolus;
then elevate extremity. A second dose (12 mg) may be given in 1-2 m in if
needed. (need 2 nurses)
•Pediatric:
Initial dose 0.1 mg/kg IV/IO (max single dose: 6 mg); second dose 0.2 mg/kg
IV/IO rapid push; followed with 5-10 ml NS flush *
.

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SPECIAL CONSIDERATIONS :
•A brief period of asystole (up to 15 sec) following conversion,
followed by resumption of normal sinus rhythm, is common after
rapid administration.*
•Reduce initial dose to 3 m g in patients receiving dipyridamole or
carbamazepine, in heart transplant patients, or if given by central
venous access.
•Patients taking theophylline or caffeine may require larger doses of
adenosine.
•Deterioration (including hypotension) may result if given for
irregular, polymorphic wide-complex tachycardia/ VT.
•Adenosine may produce bronchoconstriction in patients with
asthma and in patients with bronchopulmonary disease

15. Case no. 2
54 year old man known case of DM , HTN
presented with history of Chest pain and syncopal
episode at home .
On presentation his complain SOB, chest tightness
with two episodes of vomiting
O.E : Conscious , looks sweaty , BP 110/65
HR 94/m regular, RR 22/m , O2 sat 93 %

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17. Oxygen
Indications
* Any suspected cardiopulmonary emergency
* Critical illness conditions .
* ACS , CVA Oxygen saturation less than 94 %*
•Note: Pulse oximetry should be monitored
Precautions……
Pulse oximetry inaccurate in:
• Low cardiac output
• Vasoconstriction
• Hypothermia
• Poisoning

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Aspirin
Platelet aggregation inhibitor, anti-inflammatory agent.
Prevents platelets from clumping together, or aggregating, and forming
emboli.
Indications New onset chest pain suggestive of AMI or ACS.
Contraindications Hypersensitivity*. Relatively contraindicated in
patients with active ulcer disease or active asthma.*
Adverse reactions/side effects Bronchospasm, anaphylaxis, wheezing
in allergic patients, prolonged bleeding, GI bleeding, epigastric distress,
nausea, vomiting, heartburn.

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Drug interactions : Use with caution in patients allergic to
NSAIDs .
Dosage and administration : Adult: 160 mg to 325 mg PO.
Chewing is preferable to swallowing.
Pediatric: Not recommended.
Onset: 30–45 minutes.
Peak effect: Variable.
Duration: Variable.

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NITROGLYCERIN (GTN): Vasodilator
Nitrates and nitrites dilate arterioles and veins in the periphery (and
coronary arteries in high doses)*
•Reduce preload, and to a lesser extent in afterload .
•Decrease the workload of the heart .
•Lower myocardial oxygen demand.
Onset: 1-3 min, Duration: 30-60 min
INDICATIONS :
•Ischemic chest pain .
•Congestive heart failure .
•Hypertensive emergencies with ACS.

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CONTRAINDICATIONS : Volume depletion , Hypersensitivity ,Hypotension
Extreme bradycardia, Extreme tachycardia in the absence of heart failure,
Right ventricular infarction ,Recent use of vardenafil (Levitra), or sildenafil
(Viagra), Aortic stenosis.
ADVERSE REACTIONS : Transient headache*, Reflex tachycardia ,Hypotension
Nausea and vomiting, Postural syncope ,Diaphoresis .
DRUG INTERACTIONS : Other vasodilators may have additive hypotensive
effects. Do not mix with other drugs.
DOSAGE AND ADMINISTRATION
•Tablet: 0.4 mg sublingually; may repeat for a total of 3 doses at 5-min intervals.
• Metered spray: 1-2 sprays (0.4m g/dose) for 0.5-1 sec. at 5-min intervals;
max 3 sprays
•Intravenous : start lower dose 0.5mg/h infusion increase it according to BP and
patient complain .

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MORPHINE SULFATE : Opioid analgesic
•Has a primary effect of analgesia.
•Decreases preload , afterload and decreases venous return
•Euphoria .
•Respiratory , central nervous system depression.
Onset: 1-2 min after administration Duration: 2-7 Hr
INDICATIONS :Chest pain associated with ACS unresponsive to nitrates
Acute carcinogenic pulmonary edema* (with adequate blood pressure),
severe acute and chronic pain .
CONTRAINDICATIONS :
•Hypersensitivity to narcotics
•Hypovolemia
•Hypotension
•Use with caution in RV infarction

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ADVERSE REACTIONS Hypotension , Bradycardia ,Palpitations ,Syncope
Facial flushing *, diaphoresis, pruritus, Respiratory depression, Euphoria
Bronchospasm*,Dry mouth, Allergic reaction*
DRUG INTERACTIONS
•Central nervous system depressants may potentiate effects of morphine
(respiratory depression, hypotension, sedation).
•Phenothiazine may potentiate analgesia.
DOSAGE AND ADMINISTRATION
Adult:
•STEMI: 2-4 mg IV; may give additional doses of 2-4 mg IV at 5- to 15-min intervals
; BP ? Monitoring
•UA/NSTEMI: 1-5 mg IV only if symptoms not relieved by nitrates or if symptoms
recur (use with caution)
•Pain: 2-4 mg slow IV over 1-5 min every 5-30 min; titrated to effect
Pediatric: 0.1 mg/kg dose IV .

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SPECIAL CONSIDERATIONS
•Not used for prolonged periods or in high doses at term;
narcotics rapidly cross the placenta
•Safety in neonates has not been established.
•Use with caution in the elderly, asthma, central nervous system
depression.

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Clopidogrel (Plavix) Class Thienopyridine antiplatelet.
Mechanism of action : Inhibits platelet aggregation by blocking activation of the
glycoprotein IIb/IIIa complex
Indications :ST elevation MI (STEMI), moderate- to high-risk non-ST elevation MI
(NSTEMI), acute coronary syndrome, substitute for aspirin in patients unable to
take aspirin.*
Contraindications : Active GI bleeding, intracranial hemorrhage, known
hypersensitivity.
Adverse reactions/side effects Severe neutropenia, thrombotic thrombocytopenic
purpura (TTP), GI hemorrhage, cerebral hemorrhage, angioedema, Stevens-Johnson
syndrome
Dosage and administration Adult: Loading dose of 300–600 mg PO.*
Onset: Rapid. Peak effect: 1 hour. Duration: 7–10 days.

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Heparin Sodium Class Anticoagulant.
Mechanism of action Prevents conversion of fibrogen to fibrin. Does not lyse
existing clots.
Indications AMI , prophylaxis and treatment of thromboembolic disorders .
Contraindications Hypersensitivity, active bleeding, recent intracranial,
intraspinal, or eye surgery, bleeding tendencies, severe thrombocytopenia.
Adverse reactions/side effects Pain, anaphylaxis, shock, hematuria, GI bleeding,
hemorrhage, thrombocytopenia, bruising.
Drug interactions Salicylates, ibuprofen, dipyridamole, may increase risk of
bleeding.
Dosage and administration Adult: If used with fibrinolytic therapy,. Heparin is
given as an IV bolus of 60 U/kg max 4,000 IU (weight adjusted). A continuous
infusion is given following the bolus at a rate of 12 IU/kg/h
Onset: IV Immediate, (SQ) 20–60 minutes. Peak effect: Variable. Duration: 4–8
hours.

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RETEPLASE : CLASS Fibrinolytic
A recombinant plasminogen activator. generating plasmin which degrades the
fibrin matrix of a thrombus.
Indication : STEMI to improve ventricular function following AMI.
Onset: Causes reperfusion within 90 min for most patients Duration: Variable
should administer within 30 from patient arrival to ED
CONTRAINDICATIONS * Active internal bleeding, History of stroke, Recent
intracranial or intraspinal surgery or trauma, Intracranial neoplasm,
atrioventricular malformation, or aneurysm, Bleeding disorders ,Severe
uncontrolled hypertension
ADVERSE REACTIONS Bleeding (internal and at superficial sites),Reperfusion
dysrhythmias, Allergic reaction (rare), Nausea ,vomiting, Hypotension
DRUG INTERACTIONS. Risk of bleeding with concomitant use of heparin, vitamin K
antagonist (e.g., warfarin) is greatly increased.
Reteplase is incompatible with heparin; do not administer in the same IV line

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DOSAGE AND ADMINISTRATION :
10 units as IV bolus over 2min. ,A second 10-unit IV bolus
in 30 min. (Give NS flush before and after each bolus.)
Heparin and aspirin should be administered
concomitantly.
SPECIAL CONSIDERATIONS
•Reteplase should be given in an IV line in which no other
medication is being injected or infused simultaneously.
•Protect contents of package from light.

29. 48 year old man admitted to the ER with chest pain, dyspnea,
and palpitation . He appears in acute distress
Vital signs are: HR 190/m , RR = 24, BP = 80/40
Oxygen sat. 92%
Case No. 3

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Amiodarone Class Antidysrhythmic.
Mechanism of action Blocks sodium and potassium channels delaying
repolarization and increasing the duration of action potential.
Indications : VF ,pulseless VT, unstable ventricular tachycardia in patients refractory
to cardioversion .
Contraindications : Known hypersensitivity to amiodarone or iodine, cardiogenic
shock, sinus bradycardia, second- or third degree AV block.
Adverse reactions/side effects Dizziness, fatigue, malaise, tremor, ataxia, lack of
coordination, adult respiratory distress syndrome, progressive dyspnea,
bradycardia, hypotension, worsening of dysrhythmias, prolonged QT interval,
nausea, vomiting, burning at IV site .
Drug interactions
•Use with digoxin may cause digitalis toxicity.
•Beta blocker and calcium channel blockers may potentiate bradycardia, sinus
arrest, and AV heart blocks

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Dosage and administration
Adult
•VF /pulseless VT: 300 mg IV/IO push. Initial dose can be followed one time in 3–
5 minutes at 150 mg IV/IO push.
•Recurrent life-threatening ventricular dysrhythmias: Rapid infusion: 150 mg
IV/IO over 10 minutes (15 mg/minute). May repeat rapid infusion (150 mg IV/IO)
every 10 minutes as needed. Maximum cumulative dose: 2.2 g IV/24 h
Pediatric:
5 mg/kg IV/IO bolus. Can repeat the 5 mg/kg IV/IO bolus up to a total dose of 15
mg/kg per 24 h. Maximum single dose: 300 mg.
Onset: Immediate. Peak effect: 10–15 minutes. Duration: 30–45 minutes.
Special considerations :
•Monitor patient for hypotension.
•May worsen or precipitate new dysrhythmias

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Lidocaine Hydrochloride (Xylocaine) Class Antidysrhythmic.
Mechanism of action Decreases automaticity by slowing the rate of
spontaneous phase 4 depolarization.
Indications Alternative to amiodarone in cardiac arrest from VT, VF ,
stable wide complex tachycardia (poly- or monomorphic) with normal
baseline QT interval.
Contraindications Hypersensitivity, second- or third-degree AV block .
Adverse reactions/side effects Anxiety, drowsiness, confusion, seizures,
slurred speech, respiratory arrest, hypotension, bradycardia, dysrhythmias,
cardiac arrest, AV block, nausea, vomiting.
Drug interactions
•Apnea induced with succinylcholine may be prolonged with high doses of
lidocaine.
•Cardiac depression may occur in conjunction with IV phenytoin.
Procainamide may exacerbate CNS effect.

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Dosage and administration
•Cardiac arrest : Pulseless VT/VF : Initial dose: 1–1.5 mg/kg
IV/IO. Repeat dose: 0.5–0.75 mg/kg IV/IO repeated in 5–10
minutes. Maximum total dose: 3 mg/kg.
•Stable VT , wide VT of unknown etiology, significant ectopy:
Dose range 0.5–0.75 mg/kg and up to 1–1.5 mg/kg. Repeat
0.5–0.75 mg/kg every 5–10 minutes.

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Onset: 1–5 minutes. Peak effect: 5–10 minutes. Duration: Variable
Special considerations :
•Reduce maintenance infusion by 50% if patient is older than 70
years of age, has liver or renal disease, is in CHF, or is in shock.
•Avoid lidocaine for reperfusion dysrhythmias after fibrinolytic
therapy.
•Cross-reactivity with other forms of local anesthetics.

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Procainamide Hydrochloride Class Antidysrhythmic.
Mechanism of action Suppresses phase 4 depolarization in normal
ventricular muscle and Purkinje fibers, reducing ectopic pacemaker’s
automaticity; suppresses intraventricular conduction
Indications Stable monomorphic VT with normal QT interval, reentry SVT
uncontrolled by vagal maneuvers and adenosine, atrial fibrillation with rapid
ventricular rate in patients with Wolff-Parkinson-White syndrome.
Contraindications Polymorphic VT , second- and third degree heart block ,
QT prolongation, digitalis toxicity, tricyclic antidepressant overdose.
Adverse reactions/side effects Confusion, seizures, hypotension,
bradycardia, reflex tachycardia, ventricular dysrhythmias, AV blocks, asystole,
widening of PR, QRS, and Q-T intervals, nausea, vomiting.

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Drug interactions Increases plasma levels of amiodarone and quinidine.
Dosage and administration
Adult:
•Recurrent VF /pulseless VT : 20 mg/min
•Other indications: 20 mg/min slow IV infusion
•
Stop if any one of the following occurs :
•Dysrhythmia suppression.
•Hypotension .
•QRS widens by >50% of its pretreatment width,
•Total dose of 17 mg/kg has been given.
Pediatric: Loading dose 15 mg/kg IV/IO over 30–60 minutes.

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Onset:10–30 minutes. Peak effect: Variable. Duration:3–6 hours.
Special considerations
•Potent vasodilation and negative inotropic effects.
•Hypotension may occur with rapid infusion.
•Administer cautiously to patients with cardiac, hepatic, or renal
insufficiency; Reduce the dose
•Administer cautiously to patients with asthma or digitalis-
induced dysrhythmias.

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MAGNESIUM SULFATE CLASS Electrolyte, anticonvulsant
Blocks peripheral neuromuscular transmission by reducing acetylcholine release
at the myoneural junction. Lead to reduces muscle contractions
Onset: Immediate; Duration: 30 min
INDICATIONS
•Seizures of eclampsia (toxemia of pregnancy)
•Polymorphic VT
•Life-threatening ventricular dysrhythmias attributable to digitalis toxicity
•Suspected hypomagnesemia
•Status asthmatics not responsive to beta-adrenergic drugs
CONTRAINDICATIONS Heart block or myocardial damage
ADVERSE REACTIONS Facial flushing, Hypotension, Depressed reflexes*
Hypothermia ,Reduced heart rate, Circulatory collapse, Respiratory
depression*

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DRUG INTERACTIONS
•Serious changes in cardiac function may occur with cardiac glycosides
(avoid excess magnesium administration).
DOSAGE AND ADMINISTRATION
Adult
•Seizure activity associated with pregnancy : 1-4 g IV/10m; then 1g/h
• Cardiac Arrest : 1–2 g IV/IO over 5 min.
• Torsades w/pulse or Hypomagnesemia: 1–2g over 10-30 min IV/IO then
0.5gm –1gm/hr
• Status Asthmatics : 1-2 g over 30m ,Repeat the dose on need
Pediatric
Status asthmaticus 25-50 mg/kg IV/IO (max 2 g) over 30 min

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SPECIAL CONSIDERATIONS
•It is recommended that the drug not be administered in the 2 h
before delivery .
•IV calcium gluconate or calcium chloride should be available as
an antagonist to magnesium if needed
•Convulsions may occur up to 48 hr after delivery, necessitating
continued therapy.
•Magnesium must be used with caution in patients with renal
failure because it is cleared by the kidneys and can reach toxic
levels easily in those patients.

42. Case no. 4
60 year old man known case of DM brought by
family , History of vomiting ,poor oral intake
O.E : looks confused and sweaty
BP 110/60 , HR 100/m , RR 20/M , RBS 1mmol
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Dextrose Class Carbohydrate, antihypoglycemic.
Mechanism of action: Rapidly increases serum glucose levels.
Short-term osmotic diuresis.
Indications :
•Hypoglycemia,
•Altered level of consciousness, coma of unknown origin, seizure of unknown
origin,
• Hyperkalemia*
Contraindications : Intracranial hemorrhage.
Adverse reactions/side effects :Extravasation leads to tissue
necrosis., pulmonary edema, hyperglycemia.

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Duration of action : Onset: Less than 1 minute.
Peak effect: Variable.
Duration: Variable.
Special considerations :
•Administer thiamine prior to D 50 in known alcoholic patients.
Drug interactions : Sodium bicarbonate, warfarin (Coumadin).
Dosage and administration
• Adult: 50 ml of 50% solution slow IV push. May be repeated as necessary.
•Pediatric: 1 year and older; 4 ml /kg of a 25% solution slow IV/IO push.
May be repeated as necessary.
•Neonates and infants: 2-4 ml / kg of a 10% solution slow IV push*

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Case no. 5
34 year old man known case of depression brought by EMS
found unresponsive , Agitated .
O.E
Confused ,Irritable Dilated pupils, Dry skin
BP 90/60 , HR 110/m, O2sat 95 %,RR10/m .
Blood sugar 7 mmol /L

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Sodium Bicarbonate Class Systemic hydrogen ion buffer, alkalizing agent.
Mechanism of action Buffers metabolic acidosis and lactic acid by reacting with
hydrogen ions to form water and carbon dioxide
Indications :
•Tricyclic antidepressant, aspirin, and phenobarbital overdose.
•Metabolic acidosis during cardiac arrest.*
•Hyperkalemia .*
•crush injuries. *
Contraindications : Metabolic and respiratory alkalosis, hypokalemia.
Adverse reactions/side effects : Hypernatremia, metabolic alkalosis, necrosis at
injection site. Seizures, fluid retention, hypokalemia, electrolyte imbalance, sodium
retention, peripheral edema.
Drug interactions.
•Decreases the effects of benzodiazepines, tricyclic antidepressants.
•May deactivate sympathomimetic (dopamine, epinephrine, norepinephrine).

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Dosage and administration
•Adult: 1mEq/kg slow IV, IO push may repeat at 0.5 mEq/kg
every 10 minutes.
•Pediatric:1mEq/kg slow IV, IO push
dilute in small children to 4.2% .
Onset: Seconds. Peak effect: 1–2 minutes.
Duration: 10 minutes

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Special considerations
•Repeat as needed in tricyclic antidepressant overdose until
QRS narrows.
•Must be used in conjunction with effective ventilation and
chest compressions in cardiac arrest.
•Avoid contact with other medications; may precipitate or
inactivate them.
•Always flush IV line well before and after injecting
•Use with caution in patients with CHF and renal disease
due to high sodium concentration.
•Monitor patient closely for signs and symptoms of fluid
overload.

50. Case no. 6
68-year-old woman presented to the ED with two
days of progressive dizziness followed by syncope
on the day of presentation.
She denied chest pain or dyspnea. She had a history
of subarachnoid hemorrhage and hypertension
managed with diltiazem.

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Atropine Sulfate Class Anticholinergic agent.
Acts as a competitive antagonist of acetylcholine (ACh) at the muscarinic
receptor Increases heart rate in life-threatening Brady dysrhythmias
Indications Hemodynamically unstable bradycardia, organophosphate
poisoning, nerve agent exposure, RSI in pediatrics, beta blocker or calcium
channel blocker overdose.
Not likely to be effective for type II second-degree or third degree block
Contraindications : Tachycardia, hypersensitivity, narrow-angle
glaucoma, hypothermic bradycardia
Adverse reactions/side effects Drowsiness, confusion, headache,
tachycardia, palpitations, dysrhythmias, nausea, vomiting, pupil dilation,
dry mouth/nose/skin, blurred vision, urinary retention, constipation,
flushed, hot, dry skin; paradoxical bradycardia when pushed too slowly or
when given at low doses.

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Drug interactions
Effects enhanced by antihistamines, procainamide,
quinidine, antipsychotics, benzodiazepines, and
antidepressants.
DOSE :
• Symptomatic bradycardia 0.5 mg IV ,repeat every 5m
maximum dose 3 mg.
• Organophosphate poisoning: Extremely large doses may be needed.
• Pediatric: : 0.02 mg/kg IV/IO
Onset: Immediate. Peak effect: Rapid to 1–2 minutes. Duration: 2–6 Hr
Special considerations
• Moderate doses may cause pupillary dilation.
• Paradoxical bradycardia can occur with doses lower than 0.1 mg.

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Calcium Gluconate Class Electrolyte.
Mechanism of action :
Stabilizing the membranes of the cardiac cells
•Counteracts the toxicity of hyperkalemia .
•Reducing the likelihood of fibrillation
Indications: Hyperkalemia, hypocalcemia, hypermagnesemia,
beta blocker and calcium channel blocker overdose.
Contraindications: Digitalis toxicity *,Hypercalcemia.
Adverse reactions/side effects: Syncope, cardiac arrest,
dysrhythmia, bradycardia, asystole ,N., V., metallic taste, tissue
necrosis at injection site .

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Drug interactions
•May worsen dysrhythmias secondary to digitalis toxicity.
•May antagonize the effects of calcium channel blockers.
•Do not mix or infuse immediately before or after sodium
bicarbonate without intervening flush.
Dosage and administration
Adult: 10-20ml of 10% calcium gluconate over 10 m.
Pediatric: 0.6-1.2 ml/kg 10 % calcium gluconate over 10m .
Onset: Immediate. Peak effect: Immediate. Duration: 30m- 2H
Special considerations
Do not administer by IM or SQ; causes significant tissue necrosis

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Case no. 7
23 year old man brought by his family founded
unresponsive ,cyanotic with shallow breathing
vital sign : BP100/60 , PR 56 /m, RR 4/m ,
O2 sat. 85% RA

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Naloxone Hydrochloride Class Opioid antagonist, antidote.
Mechanism of action Competitive inhibition at narcotic receptor sites.
Reverses respiratory depression secondary to opiate drugs.
Indications
•Opiate overdose ; complete or partial reversal of central nervous
system and respiratory depression induced by opioids,
•Decreased level of consciousness and coma of unknown origin.
Narcotic antagonist for the following: Morphine sulfate, Heroin,
Hydromorphone ,Methadone, Meperidine , Fentanyl ,Oxycodone
Codeine, Propoxyphene.

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Special consideration
• Use with caution in narcotic-dependent patients. *
• Use with caution in neonates of narcotic-addicted mothers.*
Adverse reactions/side effects
Restlessness,* seizures*, dyspnea, pulmonary edema*, tachycardia,
hypertension, dysrhythmias, nausea, vomiting, withdrawal symptoms
in opioid-addicted patients, diaphoresis.
Drug interactions
Incompatible with bisulfite and alkaline solutions.

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Dosage and administration
Adult: 0.4–2 mg IM/IV/IO/SQ/ ET/Intranasal (diluted); minimum single dose*
recommended. Repeat at 5-minute intervals to a maximum total dose of 10 mg.
Pediatric: 0.1 mg/kg/dose IV/IO/IM/SQ every 2 minutes as needed. Maximum
total dose of 2 mg. If no response in 10 minutes, administer an additional 0.1
mg/kg/dose.
Onset: <2 minutes. Peak effect: Variable. Duration: 30–60 minutes.
Special considerations :
•Assist ventilations prior to administration to avoid sympathetic stimulation.
•Use caution when administering to narcotic addicts (potential violent behavior).
• Half-life of naloxone is often shorter than the half-life of narcotics; repeat
dosing may be required.

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DIAZEPAM CLASS Benzodiazepine
Indication
•Acute Anxiety States
•Acute Alcohol Withdrawal
•Skeletal Muscle Relaxation
•Seizure Activity
•Premedication Before Counter shock Or Transcutaneous Pacing
Rapid IV administration may be followed by respiratory depression
and excessive sedation, particularly in elderly patients.
Onset: (IV) 1-5 min; (IM) 15-30 min
Duration: (IV) 15 min-1Hr; (IM) 15min-1Hr

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Contraindications
•Hypersensitivity to the drug .
•Substance abuse (use with caution) .
•Coma (unless the patient has seizures or severe muscle rigidity or
myoclonus)
•Shock
•Central nervous system depression as a result of head injury
•Respiratory depression .
ADVERSE REACTIONS :Hypotension, Respiratory depression , Ataxia,
Confusion, Dizziness ,Drowsiness, Blurred vision
DRUG INTERACTIONS
•Increase CNS depression with other CNS depressant medications.
•Incompatible with most fluids; should be administered into an IV of NS
solution.
.

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DOSAGE AND ADMINISTRATION
•Seizure Activity
Adult: 5-10 mg over 2m. IV every 10-15 m in prn (max dose: 30 mg)
Pediatric: 0.1 -0.2 mg /kg max 5 mg slow IV
•Cardioversion or Transcutaneous Pacing
Adult: 5-10 m g IV, over 2 min. before procedure
SPECIAL CONSIDERATIONS :
•Diazepam may cause local venous irritation.
• Reduce dose by 50% in elderly patients.
• Rectal administration may require higher dose because absorption is
incomplete.
• Resuscitation equipment should be readily available

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Case no. 8
28 year old female brought by her family with history
of bee sting at home .
O.E puffy face, swollen lip and unable to swallow
diffuse skin rash, wheezy chest
BP 100/60 , HR 110/M , RR 22/M

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Epinephrine(Adrenalin) Class Sympathomimetic.
Mechanism of action Direct-acting alpha and beta agonist.
•Alpha: vasoconstriction.
•Beta-1: positive inotropic, chronotropic, and dromotropic effects.
•Beta-2: bronchial smooth muscle relaxation and dilation of skeletal vasculature.
•Blocks histamine receptors.
Indications
•Cardiac arrest (asystole, PEA, VF and pulseless VT ),
•Symptomatic bradycardia as an alternative infusion to dopamine,
•Severe hypotension secondary to bradycardia when atropine and transcutaneous
pacing are unsuccessful,
•Allergic reaction, anaphylaxis, asthma.
Contraindications : Hypertension, hypothermia, pulmonary edema, myocardial
ischemia, hypovolemic shock.*
Adverse reactions/side effects* Nervousness, restlessness, headache, tremor,
pulmonary edema, dysrhythmias, chest pain, hypertension, tachycardia, N,V .

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Drug interactions
•Potentiates other sympathomimetics.
•Deactivated by alkaline solutions.
Dosage and administration
Adult:
•Anaphylaxis: 0.3 mg-0.5 mg* (1:1,000) IM repeat every 5-10 m .
•Cardiac arrest: IV/IO dose: 1 mg (10 mL, 1:10,000 solution) 3–5 minutes
during resuscitation.
•Profound bradycardia or hypotension: 2–10 µg/min; titrate to patient
response.
•Higher dose: Higher doses (up to 0.2 mg/kg) may be used for specific
indications: (beta blocker or calcium channel blocker overdose).

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Pediatric:
•Anaphylaxis/severe status asthmaticus: 0.01 mg/kg (0.01 mL/kg) IM of a
1:1,000 solution (maximum single dose: 0.3 mg).
•Cardiac arrest: IV/IO dose: 0.01 mg/kg (0.1 mL/kg) of a 1:10,000 solution every
3–5 minutes during arrest.
• Symptomatic bradycardia: IV/IO dose: 0.01 mg/kg (0.01 mL/kg) of a 1:10,000
solution.
Onset: Immediate. Peak effect: Minutes. Duration : Several minutes.
Special considerations
•May cause syncope in asthmatic children.
•May increase myocardial oxygen demand.
To mix an infusion add 1 mg of epinephrine 1:1,000 to 500 mL D 5 W for a
yield of 2 mcg/mL.

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71. CRITICAL POINTS
• Know dosages, indications, contraindications and side
effects of drugs .
• Know concentrations of drugs.
• Know what drugs look like at your organization
• Read…Read…Read
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Thank you